Iealthy lifestyle behaviors may contribute to better health (Kaplan, Seeman, Cohen, Knudsen, & Guralnik, 1987) and longevity (Palmore, 1970). The Health Belief Model (Becker, 1974) proposes that adherence to healthy behaviors is a function of perceived susceptibility, severity, and threat of disease, compounded by various modifying factors. In a comparative study of preventive health behaviors Black women were less likely to practice primary prevention and more likely to practice secondary prevention behaviors than their White counterparts (Duelberg, 1992). Despite these and similar findings, previous research has failed to investigate the practice and beliefs regarding adherence to particular health behaviors in this population. The purpose of this study was to identify the health behaviors of southern, community-living Black older women and identify relationships between practice of health behaviors and health beliefs. The three primary research questions were: a) What is the adherence level of southern, community-living Black older women to 20 recommended health behaviors; b) What are the health beliefs of southern, community-living Black older women regarding the importance of adherence to 20 recommended health behaviors; and c) What relationships exist among behavior adherence, health beliefs of importance, control over health, and self-perceived health in southern Black older women?
The Health Belief Model (HBM), developed by Becker (1974), served as the theoretical perspective that guided this study. The model serves as a framework to identify differences between people who take precautions to avoid illness and those who do not. The HBM has three major components: individual perceptions; likelihood of action; and modifying factors. Individual perceptions are subdivided into three factors: susceptibility to developing a specific disease; potential seriousness of a disease's effects on an individual's life; and threat of harm considering the susceptibility and seriousness of the feared disease.
The likelihood of action component involves perceived benefits and perceived barriers related to adherence. The perception that certain recommended actions would protect one's health is coupled with real and imagined barriers to following health promotion/ disease prevention (HP/DP) recommendations. Perceived benefits may vary and possibly relate to physical, psychological, or social advantages. Perceived barriers may include cost, inconvenience, discomfort, lifestyle changes, or fear of an existing disorder within oneself. For adherence to occur, perceived benefits must outweigh perceived barriers.Modifying factors may affect both an individual's perceptions and their likelihood of action.
Modifying factors include variables such as the demographic characteristics of age, sex, race, income, and ethnicity; social and psychological factors derived from confonnance to the values, attitudes, beliefs, and behaviors of one's reference group; structural variables such as the influence of prior knowledge or previous contact with the disease or behavior; and cues to action that are internal (such as discomfort, fatigue, exhaustion, or recollection of previous experience) or external (such as mass media reports, health education, or advice from someone else).
Research has shown that older adults are more adherent to recommended behaviors than the general population (Baiiseli, 1986). Black older women are at higher risk for earlier onset of poor health (Douglass, Espino, Meyers, McClelland, & Haller, 1988; Evans, 1988; Gibson & Jackson, 1987) and disproportionate rates of impairment when compared to Black older men (Chatters, 1993; Edmonds, 1990; Martin, Engle, & Graney, 1992) and White older adults (Edmonds, 1990; Gibson & Jackson, 1987). Moreover, Black older women living in the South have been shown to have a higher risk for functional impairments than those living in other regions (Gibson & Jackson, 1987).
This descriptive, correlational study employed a survey approach to obtain cross-sectional data regarding the adherence and beliefs of community-living Black older women to various recommended health behaviors, control over health, and self-perceived health. Data were collected by means of individually administered, structured interviews and questionnaires that were conducted at one point in time.
Sample and Setting
The study employed a convenience sample of 40 Black older women who were members of a southern, urban Baptist church and physically able to attend weekly worship service. Each Black woman included in the study met the criteria of being at least 65 years of age, being able to read and write in English, residing in a non-institutional setting, willing to participate, and having the cognitive capability of appropriate response to questions. The participant response rate was 100%.The sample ranged in age from 65 to 80 years (M=71.13; SD=3.86). The majority of participants were widowed (55%), or married (38%); the remainder were either legally separated or divorced. Half of the women (50%) reported having received 8 or less years of education; none had attended college. Whereas the majority of participants were retired, 15% were employed part-time and 10% worked full-time. The mean for income adequacy, on a scale from 1 to 10, was 5.85 (SD=LSl), indicating "average amount, comfortable;" only 13% indicated that their income was "not enough to live on." Twenty-five percent reported incomes of "more than enough to live on."
Instruments used in this study include a background information questionnaire, the Health Habits/Health Beliefs Survey, a locus of control over health scale, and a self-perceived health rating scale. The background information questionnaire inquired about sociodemographic characteristics which are considered modifying variables. Age, marital status, educational background, and employment status were recorded according to participants' direct responses. Financial adequacy was assessed using a 10-rung Cantril ladder (Engle & Graney, 1985) to respond to the question, "Oo you have enough money to live on?" income level descriptor labels were at 1, indicating "not enough to live on," at 5 or 6, indicating "average amount, comfortable," and at 10, indicating "more than enough to live on." Face validity was established by confirmation of sensibility with four other registered nurses and supported by the findings of a thorough and critical review of the literature. Each item was frequently mentioned in existing literature and in the HBM itself, as important variables related to health behavior adherence.
The Health Habits/Health Beliefs Survey (Bausell, 1986) is a two-part instrument that was used to operationalize health behavior and one of the three aspects of health belief addressed in this study. Health behavior was measured as the level of adherence to 20 commonly recommended health behaviors. To obtain health behavior data, participants were asked a series of questions such as "Do you use seatbelts whenever you ride in a car?" and "Do you try to avoid salt in your diet?" The adherence score was determined as the number of "yes" responses to direct inquiry about adherence to health practices. Adherence scores could range from O (total non-adherence) to 20 (total adherence).
The aspect of health belief measured by the Health Habits/Health Beliefs Survey was the participant's belief regarding the importance of the 20 individual health behaviors in terms of enhancing and prolonging life. The level of importance for each item was assessed following each health behavior question and estimated using a ??-rung Cantril ladder (Engle & Graney, 1985) that asked the question, "How important is this habit to helping someone to live a long and healthy life?" (Bausell, 1986). Possible individual responses ranged from 1 (not important) to 10 (very important). Higher scores indicate higher perceived importance of the specific health behavior. The group mean for rating of importance in individual items and the overall mean for perceived importance of the 20 behaviors could be estimated from health belief importance data.
The Health Habits/Health Beliefs Survey was proven to be a valid and reliable measure of adherence to health behaviors and health beliefs of importance. The standardized item alpha coefficient of .80 was reported by Bausell (Personal communication, November, 1987), however, the Cronbach's coefficient alpha for the present study was .51. Bausell (Personal communication, November, 1987) further reported that content validity of the entire instrument was established through the ratings of 100 public health experts. Face validity was supported by the abundance of literature demonstrating assessment of some or all of these behaviors. The team of public health experts further agreed that each of the 20 health behavior items were of great importance in relationship to health status.
A simple locus of control over health scale was employed as the second measure of health belief. The belief measured by this scale referred to the believed amount of control the individual had over their future health (Bausell, 1986). To measure this belief of control over health, participants were asked, "How much control do you think you have over your future health?" Using a third 10-rung Cantril ladder, participants rated their level of control from 1, signifying "no control", to 10, signifying "complete control." Higher scores indicate higher perceived control over health. Face validity was supported by the previous literature suggesting the correlation between locus of control and health status of chronically ill adults (Edelstein & Linn, 1987).
A self-perceived health rating scale was used to measure the third and final component of health belief, self-perceived health. Participants were asked to respond to the question, "Compared to other Black women your age, how would you rate your health today?" (Cockerham, Sharp, & Wilcox, 1983). A fourth 10-rung Cantril ladder with calibrations from 1 (much worse than most) to 10 (much better than most) was used for participant response to this item. Higher scores indicate better health. Reliability of self-perceived health has long been established (Maddox, 1962; Magnani, 1990). Validity of self-perceived health, using Likert scales, was established in previous research with Black older women (Gibson, 1991; Gibson & Jackson, 1987) and in a general sample of older adults (Bausell, 1986).
The study was granted Institutional Review Board approval and waiver of signed consent from the University. Waiver of signed consent allowed participation of persons uncomfortable with signing documents. Permission and support was also obtained from the church's pastor who informed the congregation of the study and solicited the participation of willing church members. Names and telephone numbers of interested women were submitted to the church clerk who, in turn, relayed the information to the researcher.
Each interview was conducted by the primary researcher in the privacy of individual participants' homes. The researcher read aloud the informed consent to participants; informed consent assured confidentiality and the freedom to refuse participation or withdraw from the study without penalty. Each woman gave verbal consent for participation. Each questionnaire was then read aloud by the researcher while participants reviewed a reference copy during the interview. The researcher recorded all responses on a separate form in order to insure timely expedition of the interview process. Each interview was completed in approximately 20 minutes.
Statistical programs for all data analyses were run using SAS software (SAS Institute, Inc., 1990; Schlotzhauer & Littell, 1987). Measures of central tendency were computed for adherence scores, health beliefs regarding the importance of adherence behaviors, locus of control over health, and self-perceptions of health. Normality plots were computed for all continuous data. Pearson product-moment and Spearman rank-order correlations were computed to estimate the levels of association between: a) health behavior mean adherence scores and health beliefs of importance for each of 20 recommended behaviors; b) health behavior mean adherence scores and the health belief of importance overall mean rating; c) health behavior mean adherence scores and locus of control over health; d) health behavior mean adherence scores and self-perceived health; and e) self-perceived health and locus of control over health. The minimal level of acceptable statistical significance for all study analyses was p≤05.
The mean adherence score for mis sample of southern Black older women to 20 recommended health behaviors was 16.65 (range=l2.0Q-20.00, SD=LTT). The average adherence for these women was positive in 85% (17) of the 20 recommended health behaviors. Thus, data indicate that these Black older women had a high level of adherence to the 20 recommended health behaviors.
The behaviors practiced by the majority of participants included: annual blood pressure evaluation; dietary avoidance of salt, fat, cholesterol, and sugar; dietary inclusion of adequate amounts of fiber, vitamins/minerals, and calcium; weight control; not smoking; not allowing self or others in the home to smoke in bed; adequate sleep; stress management; weekly socialization; low alcohol intake; and home safety. Health behaviors practiced by fewer participants include annual dental examinations (28%, n=11), regular exercise (33%, n=13), and seatbelt use (48%, n=19). Table 1 presents the frequencies and percentages for adherence to each of the 20 recommended health behaviors.
The overall mean for sample ratings of importance assigned to each health behavior was 9.36 (SD=LOl, ran£e=8.40-10.00). This finding indicates that Black older women perceived that all 20 health behaviors have a high degree of importance in helping persons to live a long and healthy life. Mean and standard deviation data for believed importance of each health behavior are reported in Table 1. The mean locus of control over health and self-perceived health scores were 7.65 (SD=1.79) and 8.15 (SD=2.03), respectively.
Association Between Adherence and Beliefs of Importance
Normality plots revealed nonparametric distributions of all continuous data. For this reason all reported correlations were computed using the more conservative. Spearman's rank correlation procedures (Dawson-Saunders & Trapp, 1990). Mean adherence scores for individual health behaviors were significantly correlated with beliefs of importance for 4 of the 20 recommended behaviors; smoke detector use, seatbelt use, adequate sleep, and blood pressure awareness. The association between adherence and importance of dietary avoidance of sugar bordered statistical significance. Correlation coefficients were indeterminable for seven of the remaining items because of inadequate variability, as each was practiced by all participants. Included in Table 1 is a report of correlation coefficients between health behavior adherence and beliefs of importance for each of the 20 individual behaviors. Findings suggest that the level of a Black older woman's adherence to health behaviors is not always related to how important the behavior is perceived.
Descriptive and Correlational Data for Health Behavior Adherence and Beliefs of Behavior Importance (N=40)
Associations Among Adherence, Importance, Control Over Health, and Serf-Perceived Health
A statistically significant association existed between mean adherence scores and self-perceived health (r=.55, p<.001). No significant correlations were found to exist, however, between mean adherence scores and locus of control over health (T= - .06, p=.72), mean adherence scores and health beliefs of importance overall mean rating (T=- .01, p=.94), nor between self-perceived health and locus of control over health r=.ll, p=.50). The correlation matrix presented in Table 2 depicts the interrelationships among major study variables of health behavior, mean behavior importance, control over health, and self-perceived health.
Findings of this study revealed that southern, community-living Black older women generally have a high level of adherence to commonly recommended health promotion/disease prevention habits. Study findings may be generalized to southern, community-living Black older women who regularly attend Baptist churches. This study, like others that have examined health practices of older adults (Baiiseli, 1986; Branch & Jette, 1984; Fries, 1980; Kaplan, Seeman, Cohen, Knudsen, & Guralnik, 1987; Lambert, Netherton, Finison, Hyde, & Spight, 1982; Palmore, 1970; Rauckhorst, 1987; Stenback, Kumpulainen, & Vauhkonen, 1978), demonstrated that this age group adheres least frequently to regular exercise, yearly dental attention, and smoke detector use. Seatbelt use by this group was the most poorly practiced behavior when compared to older adults in Bausell's (1986) study; some participants volunteered that low adherence to this behavior is reportedly related to "fear of being pinned or trapped in the car" in the event of an accident when a seatbelt is fastened. The majority of participants report getting an adequate amount of sleep at night, unlike the older adult group studied by Baiiseli (1986). The more frequently practiced behaviors of abstinence from alcohol and cigarettes were probably related to the participants' Southern Baptist doctrines. Two participants even volunteered that it is "sinful to do anything that is destructive to your body because the body is your temple." Findings related that social contacts are consistent with the literature on older adults in general (Krause, 1987; Seabrooks, Kahn, & Gero, 1987) and Black older women in particular (Taylor & Chatters, 1986).
Interrelationships* Among Health Behavior, Mean Behavior Importance, Control Over Health, and Self-Perceived Health (N= 40)
The overall high level of this sample's adherence to the 20 behaviors appears to reflect the perceived susceptibility, severity, and threat of chronic disease development or complications that may result from their older age and race. This impression is consistent with previous findings that suggest that health practices serve to lower an individual's morbidity and mortality risks (Kaplan, Seeman, Cohen, Knudsen, & Guralnik, 1987; Lambert, Netherton, Finison, Hyde, & Spight, 1982; Palmore, 1970). A most likely explanation for the high levels of adherence may stem from their high self-perceptions of health; the suggested perception supports previous findings by Branch and Jette (1984) that they feel well because they practice healthy behaviors which help them to maintain a healthy state. Furthermore, healthy practices for these participants may be influenced by religious doctrines that discourage certain unhealthy practices such as excessive alcohol consumption, cigarette smoking, and ineffective coping outlets; this perception is supported by Clavon & Smith (1986) in their study of Black older adults. Several participants of this study further validated this influence with anecdotal remarks including "Christians shouldn't spend useless time worrying over things. ..you have to put it in the Lord's hands." Areas of poor adherence may be reflective of explanations found in the literature including lack of understanding or perceived barriers of inconvenience, cost, fear, or mistrust related to the benefits of exercise, seatbelt use, dental attention, and smoke detector use.
Practice of healthy behaviors was not always associated with perceived importance of that behavior; one explanation for this finding may involve the sociohistorical context of social, economic, and cultural deprivation related to having always lived in the south with low income levels. Economic and social deprivation would logically equate to low levels of control, thus, it came as no surprise that although control over health was related to perceived importance of behaviors, it was not related to practice of that behavior. Historically, resources were primarily inaccessible for preventive dental attention, acquiring smoke detectors, or finding safe and acceptable locations in which to exercise until recent years. Moreover, seatbelts may be uncomfortable, inconvenient, and misunderstood by this sample of Black older women.
Clearly, study findings have several clinical implications. Increased attention must be directed to patient education regarding primary prevention. Because study findings indicate that Black older women want to maintain their health, increased attention must be directed to the importance of primary prevention behaviors as an assertion of control over one's future health, well-being, and quality of life. Nurses must set into place interventions that will enhance the perception of relevance regarding the lifestyle practice of regular exercise. Regular community-based exercise classes in churches, residential settings, senior centers, or other frequently attended community sites would increase the likelihood of regular participation in exercise.
Cost may be a major factor explaining why Black older women seldom receive preventive dental care. Therefore, the attempt must be made to locate resources to provide some of these dental services. A community health fair might prove the perfect setting for simple dental examination and cleaning provided by dental students or dental hygienists. Complicated cases could then be referred for office examination and treatment by a university-affiliated dentist or student. This mass assessment would provide a great opportunity for dental students to meet learning needs by securing clients who have specific dental problems while providing low-cost dental care to persons in need of attention.
The problems of failure to use smoke detectors and seatbelts might be resolved by involving local fire and police departments in the development of behavioral programs for community-living older adults. The fire and police departments of some larger cities will provide, upon request, community-based educational sessions for older adults. Fire safety sessions include information such as the risks of death from smoke when asleep, how to most safely move about a smoke-filled room, and precautions to prevent fires in the home. Free smoke detectors are available upon request to low socioeconomic and older adults by some fire departments. The police department has the capability to teach, with various visual aids, what happens to vehicle occupants during a collision. These visual aids along with statistics might convince participants of the protective benefits of regular seatbelt use. Nurses must more efficiently use available community resources available through the local fire and police departments and disseminate this information to older adult groups who might otherwise have knowledge deficits in fire and car safety health protective behaviors.
Thus, Black older women have a good understanding of some of the risk factors for chronic disease and poor health, yet they appear unaware of others. Improved understanding regarding all known health risk factors may increase their adherence. Nurses planning health promotion/disease prevention programs must be cognizant of the warning by Cox and Wachs (1985) that "global health education" is often inappropriate in attempts to effect behavioral change. Thus, identification of specific motivators that positively influence improvement in areas of health behavior deficit would be vital in attempts to improve the mortality and morbidity of Black older women.
The current study underscores the need for further investigation of methods that increase adherence to health promoting and disease preventing behaviors. Also apparent is the need to identify and promote any factors which may positively affect adherence and perceptions of control over one's own health. As a result of skillfully developed activities to improve their health practices and priorities, Black older women might have a lessened incidence of early onset and complications of chronic illnesses. More favorable mortality and morbidity rates are likely to influence the higher levels of subjective and objective health, well-being, and quality of life in Black older women.
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Descriptive and Correlational Data for Health Behavior Adherence and Beliefs of Behavior Importance (N=40)
Interrelationships* Among Health Behavior, Mean Behavior Importance, Control Over Health, and Self-Perceived Health (N= 40)